ALICAM Patient Info Form

Patient Information Form
Veterinarian and Hospital Information
Veterinarian Name

First NameLast Name
Email where report will be sent
The report will be sent to this email address
Clinic Name
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Clinic Phone Number
Patient Information
Patient Name
Client Last Name
Patient ID
Your clinic's ID for this patient
Breed
If other, write in breed
Age (years/months)
Weight (kg)
Sex
Capsule Serial Number
ex: G1234.9876 or A006BV.539
Date Capsule Administered

MonthDayYear
Date Capsule Retrieved

MonthDayYear
Duration patient was fasted (hours)
Clinical History
Brief summary of the progression of clinical signs and reason for ALICAM
Duration of clinical signs
Clinical signs (check all that apply)

Other
Characterize the stools (check all that apply)

Other
Does this patient have vomiting or regurgitation? (check all that apply)

Other
Appetite
Does this patient have weight loss?
Body Condition Score (9-point scale)
Current Diet

Other
Diagnostic Test Results
Radiographs taken
Radiograph results
Ultrasound performed
Ultrasound results
Ultrasonographer

Other
Endoscopy performed
Endoscopy location
Was endoscopy performed at the same time ALICAM was administered?
Were biopsies taken?
Biopsy results
CBC, chemistry panel, UA abnormalities
Fecal tests
Other tests (ie PLI, TLI, Cobalamin, Folate)
Imaging Findings
Current Treatment
Prokinetics
Prokinetic

Other
Corticosteroids

Other
Corticosteroid Dose/Frequency (mg/kg)
Antibiotics

Other
Antibiotic Dose/Frequency (mg/kg)
Gastroprotectants

Other
Gastroprotectant Dose/Frequency (mg/kg)
Antiemetics

Other
Antiemetic Dose/Frequency (mg/kg)
Other Medications
Was there a response to these medications?
Additional Medical History
Other Non-GI Diseases
Additional Pertinent Information
Upload medical records, labs, or previous imaging reports

Upload a File

Cancelof
Additional Files

Upload a File

Cancelof
Additional Files

Upload a File

Cancelof
Agree with Terms and Conditions?
Should be Empty:

Veterinarian and Hospital Information

Patient Information

Clinical History

Diagnostic Test Results

Current Treatment

Additional Medical History